TEE Gets ICEd for TAVI

Action Points

Explain that a study found that intracardiac echocardiography (ICE) was superior to transesophageal echocardiography (TEE) during transcatheter aortic valve implantation due to its ability to provide data throughout the procedure.

Note that ICE allowed for sedation and local anesthesia as opposed to general anesthesia but the tests were only conducted with a specific type of aortic valve.

Compared with the transesophageal approach, the intracardiac echo allowed continuous guidance with a significantly lower need for probe repositioning during the procedure (0.1 versus 5.7 maneuvers, P<0.001), Thomas Bartel, MD, and colleagues from Medical University Innsbruck in Austria, reported.

So that TEE didn't interfere with optimal fluoroscopic viewing, monitoring had to be interrupted for preinterventional and postinterventional angiography of the ascending aorta, one to three balloon dilatations of the native valve, final positioning and, if necessary, repositioning of the balloon catheter carrying the valve prosthesis immediately before valve deployment, according to the study published online in the Journal of the American Society of Echocardiography.

"Each withdrawal and repositioning of the transesophageal probe was explicitly requested by the interventional operator," Bartel and colleagues wrote.

Intracardiac echo is compatible with sedation and local anesthesia, while transesophageal echo requires general anesthesia. "Because TAVI can now be performed under only sedation and local anesthesia, TEE is often omitted," researchers noted.

While both imaging modalities have advantages and limitations, investigators specifically sought to compare them with respect to the "intraprocedural diagnostic information particularly important for safety and technical success immediately before device deployment, during implantation, and thereafter."

They also wanted to determine how well each method fit into the procedural work flow.

For the study, they randomized 50 patients with severe aortic stenosis who were undergoing TAVI to either transesophageal echo monitoring or intracardiac echo guidance (25 patients each). Patients were treated either by transapical antegrade or transfemoral retrograde TAVI.

Procedural success was achieved in all patients and no complications related to ICE or TEE occurred.

Intracardiac echo more frequently visualized both coronary ostia (72% versus 4%, P<0.001), as well as the right coronary ostium (92% versus 12%, P<0.001, whereas the left coronary ostium was displayed equally well by both methods (76% versus 72%, P=0.736).

Also, researchers found no statistical difference between the two methods in their ability to detect paravalvular or transvalvular leaks.

"In many patients, reverberations from the calcified native valve and the valve carrying stent impeded transesophageal echocardiographic visualization of the right coronary ostium more than the left coronary ostium. Because of sonic coaxiality, this effect is less pronounced with ICE, because neither ostium is significantly superimposed by sonic shadowing," Bartel and colleagues wrote.

The authors said that current guidelines do not provide detailed suggestions for the intraprocedural use of echocardiography. While the results from this study "confirm previous investigations demonstrating ICE and TEE to be equally safe," ICE may offer more advantages including the use of local anesthesia with sedation and numerous work flow enhancements.

The study was limited by its small size and the inability to compare ICE and TEE in the same patient, as well as the inability to estimate the actual risk associated with ICE.

Also, the investigators noted that the results cannot be "easily transferred" to TAVI using a valve other than Sapien (Edwards Lifesciences) or an ICE catheter other than the AcuNav (Siemens Healthcare).

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